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J Health Popul Nutr. 2007 Mar; 25(1): 47–61. PMCID: PMC3013263

PMID: 17615903

Gender Differences in Determinants and Consequences of Health and Illness

Carol Vlassoff

Abstract

This paper uses a framework developed for gender and tropical diseases for the analysis of non-com‐
municable diseases and conditions in developing and industrialized countries. The framework illus‐
trates that gender interacts with the social, economic and biological determinants and consequences
of tropical diseases to create different health outcomes for males and females. Whereas the frame‐
work was previously limited to developing countries where tropical infectious diseases are more
prevalent, the present paper demonstrates that gender has an important effect on the determinants
and consequences of health and illness in industrialized countries as well. This paper reviews a large
number of studies on the interaction between gender and the determinants and consequences of
chronic diseases and shows how these interactions result in different approaches to prevention, treat‐
ment, and coping with illness. Specific examples of chronic diseases are discussed in each section
with respect to both developing and industrialized countries.

Key words: Gender identity, Health, Tropical medicine, Developing countries, Developed countries,
Chronic disease, Impact studies, Review literature

INTRODUCTION

Gender refers to “the array of socially constructedBack

rolestoand
Toprelationships, personality traits, atti‐
tudes, behaviours, values, relative power and influence that society ascribes to the two sexes on a
differential basis. Gender is relational—gender roles and characteristics do not exist in isolation, but
are defined in relation to one another and through the relationships between women and men, girls
and boys” (1). Simply put, sex refers to biological differences, whereas gender refers to social differ‐
ences.

In the last decade, a considerable amount of research has been conducted in the area of gender and
health, including gender differences in vulnerability to, and the impact of, specific health conditions.
Gender has been shown to influence how health policies are conceived and implemented, how bio‐
medical and contraceptive technologies are developed, and how the health system responds to male
and female clients (2).

Gender analysis in health has been undertaken mainly by social scientists who observed that biolog‐
ical differences alone cannot adequately explain health behaviour. Health outcomes also depend
upon social and economic factors that, in turn, are influenced by cultural and political conditions in
society. To understand health and illness, both sex and gender must be taken into account.

This paper builds upon a gender framework from the field of tropical diseases (3) by examining to
what extent the framework applies equally to non-communicable diseases. The framework includes
the social, economic and personal/biological determinants and consequences of tropical diseases
and analyzes how gender interacts with these factors to produce different outcomes for males and
females. For example, the gender differences in the social determinants of tropical diseases include
the different roles of men and women in the household, status within the household and community,
and cultural norms affecting risks of infection. These factors influence exposure of women and men
to diseases such as malaria because men are more likely to be exposed to mosquitoes in certain work
environments such as forestry or mining (3). The gender differences in the consequences of tropical
diseases include how illness is experienced, treatment-seeking behaviour, nature of treatment, and
care and support received from the family and care providers. In the case of HIV-associated disease,
for instance, the economic consequences may be worse for women who are left with families to sup‐
port when husbands become infected and die, or they may not be able to earn income or support
their families when they themselves are ill.

Whereas this framework previously was limited only to developing countries where tropical diseases
are mainly found, this paper expands the analysis to include industrialized countries as well. The
paper brings together the findings of various studies to identify how gender interacts with the deter‐
minants and consequences of health and illness. Whereas previous research based on this framework
was limited to developing countries, the present analysis demonstrates that gender has an important
effect on the determinants and consequences of non-communicable diseases and conditions in both
developing and industrialized countries. In each section of the paper, one example of a chronic dis‐
ease or condition is provided to illustrate how the gender framework can be equally applied to devel‐
oping and industrialized societies.

There is no systematic body of knowledge on gender and chronic diseases, although there is a con‐
siderable literature emerging on specific diseases such as those discussed in this paper. Based on
research findings on gender, several hypotheses have been proposed. Verbrugge, for example, argued
that gender differences are more pronounced for prolonged, mild conditions than for acute, life-
threatening or severe ones (4). However, further research on specific diseases, including tropical in‐
fectious diseases, has added new findings that need to be taken into account. Charmaz notes the im‐
portance of examining gender differences in non-communicable diseases and that the experience of
illness is strongly related to gender identities (5).

The following analysis, therefore, brings together two areas of investigation—tropical infectious dis‐
eases and chronic non-communicable diseases—by showing that the framework from tropical dis‐
eases also applies to chronic diseases. It also draws out conclusions regarding gender and chronic
diseases by comparing the results of the various studies of different diseases or conditions.

MATERIALS AND METHODS

This paper is based on a review of published articles in the area of gender and health. By way of
illustration, examples of non-communicable diseases or conditions are highlighted under the head‐
ings of social, economic and biological determinants and consequences respectively to demonstrate
their interaction with gender variables. The examples are not related to one another but have been
selected because they have been studied in both developing- and industrialized-country context and
because they demonstrate the interaction of gender variables with social, economic and biological
factors and how these produce different outcomes for males and females.

RESULTS

Gender differences in determinants of health and illness

This section reviews evidence of gender differences in the social, economic and biological determi‐
nants of health and illness, focusing on three non-communic-able diseases or conditions: nutrition
for social determinants, mental illness for economic determinants, and longevity for biological de‐
terminants.

Gender differences in social determinants of health and illness Social factors, such as the degree to
which women are excluded from schooling, or from participation in public life, affect their knowl‐
edge about health problems and how to prevent and treat them. The subordination of women by
men, a phenomenon found in most countries, results in a distinction between roles of men and
women and their separate assignment to domestic and public spheres. The degree of this subordina‐
tion varies by country and geographical or cultural patterns within countries, however, in developing
areas, it is most pronounced. In this section, the example of nutrition will demonstrate how gender
has an important influence on the social determinants of food-consumption patterns and hence on
health outcomes.

Several studies have shown the positive relationship among education of mothers, household auton‐
omy, and the nutritional status of their children (6, 7). During the first 10 years of life, the energy
and nutrient needs of girls and boys are the same. Yet, in some countries, especially in South Asia,
men and boys often receive greater quantities of higher quality, nutritious food such as dairy prod‐
ucts, because they will become the breadwinners (7–15). Das Gupta argued that depriving female
children of food was an explicit strategy used by parents to achieve a small family size and desired
composition (13). Studies from Latin America also found evidence of gender bias in food allocation
in childhood (16–18) and, correspondingly, in healthcare allocation (19).

In developing countries, most studies show preferential food allocation to males over females. None‐
theless, some studies have found no sex differences in the nutritional status of girls and boys (20–
22), and others have described differences only at certain times of the life-cycle. For example, re‐
search in rural Mexico found no nutritional differences between girls and boys in infancy or
preschool, but school-going girls consumed less energy than boys. This was explained by the fact
that girls are engaged in less physical activity as a result of culturally-prescribed sex roles rather
than by sex bias in food allocation (23).

Studies from developing countries of gender differences in nutrition in adulthood argue that house‐
hold power relations are closely linked to nutritional outcomes. In Zimbabwe, for example, when
husbands had complete control over all decisions, women had significantly lower nutritional status
than men (24). Similarly, female household heads had significantly better nutritional status, suggest‐
ing that decision-making power is strongly associated with access to and control over food re‐
sources. Access of women to cash-income was a positive determinant of their nutritional status. In
rural Haiti, the differences in nutritional status for male and female caregivers were examined for
children whose mothers were absent from home during the day. Those who were looked after by
males, such as fathers, uncles, or older brothers, had poorer nutritional status than children who
were cared for by females, such as grandmothers or sisters (25). Ethnographic research conducted by
the authors revealed, however, that, while mothers told the interviewers that the father stayed home
with the children, it is probable that the father was, in fact, absent most of the day working and that
the children were cared for by the oldest child, sometimes as young as five years of age.

The involvement of both men and women in nutritional information and interventions is key to their
successful implementation. Unfortunately, in most developing countries, women are selected for
nutritional education because they are responsible for the preparation of meals. However, they often
lack access to nutritional food because men generally make decisions about its production and pur‐
chase. Similarly, men may not provide nutritional food for their families because they have not re‐
ceived information about nutrition. The participation of both men and women is, therefore, funda‐
mental to changing how decisions about food are made and food-consumption patterns and nutrition
families (26). The study in rural Haiti referred to above also found positive outcomes through the
formation of men's groups which received information on nutrition, health, and childcare. These
men, in turn, were resources for education of the whole community (25).

The gender differences are also found in the social determinants of nutrition in industrialized coun‐
tries, although their manifestations are different. For example, gender plays an important role in de‐
termining risk factors for eating disorders, which influence nutritional outcomes. The most common
of these are anorexia nervosa, bulimia nervosa, and binge eating (BED) (27–28). The root causes are
only partly understood. Biomedical and psychological theories include hormonal imbalance, mal‐
functioning of serotonin in the brain, genetic explanations, and emotional problems expressed by
abnormal relationships with food. Sociocultural explanations include the emphasis placed on the
‘ideal’ female body shape in western society. Experts agree that a key factor is the desire to please
others. These characteristics are linked to ‘negative femininity’—behaviours associated with passiv‐
ity, dependence, unassertiveness, and low self-esteem. Dieting and bingeing may be used for im‐
proving body image and self-esteem. Concern with body image is particularly strong in adolescence
where the differences in calcium intake and a more sedentary lifestyle are pronounced (29). Results
of a study of 1,755 adolescents in the United States also showed that, during adolescence, intake of
fruits and vegetables was generally low for both boys and girls and that their consumption was relat‐
ed to consciousness about controlling their weight (30). Among men, dieting and bingeing seem to
be more common among gay men and sports competitors than in heterosexuals (31).

Many studies have demonstrated the effect of social support on nutrition in older adults, with a posi‐
tive impact being seen among those who are married, especially men (32–34). This has been ex‐
plained by several factors—the greater likelihood to skip meals when living alone, or to eat filling
but unhealthy products and snacks. Women who are alone may not be able to afford an adequate
diet, or they may be less motivated to cook for themselves when they are accustomed to providing
for others (35–36).

The gender differences in nutritional risk were studied among an older sample of black and white
community dwelling residents in Alabama, USA (37). The study took into account social support,
social isolation, and social capital as possible determinants of nutritional risk. Social capital was
defined to include neighbourhoods, trust people felt in their security, and religion. The study found
important gender and racial differences between different groups, black men being the most affected
by poor nutrition if lacking in social support and capital. White men were in the best overall posi‐
tion, with white women in the second best position, and black women in the third. The study found
that social isolation and lower income contributed most to nutritional risk for all groups, except
black men, for whom lack of social support and capital were the most important determinants of
nutritional risk.

The studies discussed in this section demonstrate that gender matters in terms of nutritional out‐
comes, but, at the same time, generalizations as to how gender affects the social determinants of nu‐
trition can be misleading. The complexity of social, economic and cultural contexts and also demo‐
graphic and epidemiological indicators must be taken into account to fully understand the additional
impact that gender has.

Gender differences in economic determinants of health and illness

Productive labour is usually defined as labour performed outside the household in income-generat‐
ing employment; reproductive labour includes work done within the household, such as food prepa‐
ration, childcare, housework, care of livestock and kitchen gardens. Reproductive labour, in addition
to reproducing the daily conditions of domestic survival, also assures the reproduction of human
values, attitudes, and culture. In both industrialized and developing countries, women spend consid‐
erably more time than men in reproductive, volunteer and other unpaid labour, whereas men spend
significantly more time in productive, remunerated work (3).
In most cultures, productive and reproductive activities are valued differently. Generally, earning an
income brings greater autonomy, decision-making power, and respect in society. Given the greater
involvement of men in the paid labour force and their higher earnings even when domestic and other
activities of women are costed, they generally enjoy more autonomy and higher social status. The
gender differences in economic status and purchasing power affect the health-seeking behaviour and
health outcomes of men and women. Recent schools of thought have recognized that many types of
non-market or reproductive labour are also productive. For example, gender-aware economics in‐
cludes unpaid caring work in the home in the concept of productive labour and informal paid work,
such as home-based income-generating activities and work in non-profit or non-governmental orga‐
nizations.

Research on gender and the economic determinants of health and illness is relatively scarce, espe‐
cially in the area of non-communicable diseases. The example of mental health is used here because
there is considerable research on this topic in industrialized countries, and some studies can also be
cited from developing countries. The relative paucity of research on gender and economic aspects of
mental health in developing countries reflects the fact that mental health services are less numerous
and comprehensive than those in industrialized countries. Nonetheless, interesting studies have been
carried out in several countries that demonstrate a clear relationship between economic factors and
mental health by gender.

A study of gender and mental health in China that combined historical, epidemiological and qualita‐
tive data found significantly higher rates of schizophrenia among women than among men, a finding
contrary to western studies in which men suffer more from schizophrenia (38). Interestingly, howev‐
er, men occupied more hospital beds than women in psychiatric hospitals, in which at least three-
quarters of patients were suffering from schizophrenia, indicating that hospital-bed occupancy did
not reflect the male-female ratio of people affected by the disease. While several possible reasons for
this imbalance were cited, significant gender differences in ability to pay were noted. Men were
much more likely to have health insurance from their employers than women, who tended to be
treated more as charity cases. Reports from other parts of the world show that women constitute the
large majority of individuals seeking psychological services (39). Given this gender imbalance, ser‐
vices are not positioned to respond adequately to their female clients (40).

The gender differences in the economic determinants of mental health were also encountered in
South Korea. A recent study examined the impact on men and women of escalating job insecurity
due to increasing numbers of non-standard workers. The proportion of non-standard workers was
considerably higher among women than among men. In general, non-standard workers (part-time,
temporary, and daily labour) were more likely to suffer from mental problems than standard employ‐
ees, and non-standard female workers suffered more mental illness than men, in terms of self-report‐
ed depression and suicidal thoughts (41). Married women reported more psychological problems
than single women, and the pattern was reversed for men.

The links among mental health, gender, and economic status were clear in several aspects of the Ko‐
rean study. Women had about twice the incidence of poor mental health indicators than men, and the
mental health problems increased as income declined. This is also true of other studies (42–44). The
reasons within the Korean context were explained by Kim et al. (41) by the fact that, even among
non-standard workers, men tended to occupy higher-level positions in construction and manufactur‐
ing, whereas women were employed more in unskilled jobs. The average wage for women was less
than 40% of that of men, and only a tenth of women received fringe benefits. Women also had many
other family responsibilities which they had to fulfill, in addition to their paid labour.

Results of research in industrialized countries consistently indicate that women have higher rates of
anxiety and depression than men, independently of race, time, age, and rural-urban residence. The
fact that men have greater control over resources, and decision-making power is one explanation,
but there is considerable evidence that even when women have control over resources and income
through employment anxiety and depression is not necessarily reduced (45). A national cross-sec‐
tional survey of British adults found that people in the most disadvantaged socioeconomic positions
reported higher rates of affective disorders and minor physical illnesses than those in higher posi‐
tions. The gender differences were found in the other socioeconomic classes. Among healthy older
women, for example, those in the skilled occupational class reported the highest rates of affective
disorders, whereas among men, the highest rates were found in the clerical class. Generally, in posi‐
tions occupied by both the sexes, and among men and women with similar income levels, women
reported higher rates of both affective disorders and minor physical morbidity (46). The authors
concluded that the experience of a particular social or occupational position might be different for
men and women, explaining why women consistently experience more affective disorders and minor
physical morbidity.

In an analysis of gender, employment, and mental health, Rosenfield compared men and women
from the United States using measures of power in work and family, demands on time and personal
control, and symptoms of depression and anxiety (45). Men and women with similar demands on
their time in family and work situations had similar symptoms of psychological distress. However,
women in situations of higher demands, either as unemployed housewives or as working women
with significant familial responsibilities, had higher rates of depression and anxiety than men. Thus,
the gender differences in economic roles strongly influence mental health outcomes.

Gender differences in biological determinants of health and illness

The gender differences in the biological determinants of health and illness include differential genet‐
ic vulnerability to illness, reproductive and hormonal factors, and differences in physiological char‐
acteristics during the life-cycle. Until recently, a male model of health was used almost exclusively
for clinical research, and the findings were generalized to women, except for the reproductive peri‐
od. Clinical trials typically excluded women to protect them and their unborn children from possible
negative effects. However, research in the United States in the early 1990s seriously questioned the
validity of a male model for female health issues and highlighted significant gender differences in
the biological determinants of health and illness (47). For example, protocols for the diagnosis and
treatment of heart disease, the number one cause of all deaths in the United States, were based upon
findings from middle-aged white male patients. As a result, women were diagnosed later with more
advanced disease and were consequently harder to treat successfully.
Questions about gender differences in heart disease, mental illness, and osteoporosis led to the im‐
portant recommendation that women be included in clinical studies to uncover gender differences
and their impact on the prevention, diagnosis, and treatment of disease. In 1993, the U.S. Food and
Drug Administration established an Office of Women's Health and published “Guidelines for the
Study and Evaluation of Gender differences in the Clinical Evaluation of Drugs” which ended the
policy of exclusion, recommending that women be appropriately represented in clinical studies and
that their findings be analyzed from a gender perspective (48). Such policies are still not implement‐
ed in most of the developing world.

The interaction between biological and social determinants is also important when considering gen‐
der differences in health. The biological differences can be amplified or suppressed by socialization
and how society responds to sex-specific behaviour. Social norms endorsing particular kinds of be‐
haviour may exacerbate negative tendencies, such as violence, or reinforce positive propensities,
such as nurturing. By contrast, socialization can suppress innate negative or positive tendencies.

The example of longevity is used here for demonstrating how gender affects the biological determi‐
nants of health conditions. Universally, women live longer than men but the gender gap is greatest in
developed societies where women outlive men by about seven years, on average (49). The most ap‐
parent gender difference in the ageing process is women's finite period of reproductive functioning.
Their menopausal transition is associated with mood fluctuations and a decline in sexual interest
relating to hormonal change. As they age, men and women suffer from similar types of illnesses but
men tend to suffer from acute illnesses for relatively short periods before they die (49). Women, by
contrast, have a longer life, marked by many chronic non-life-threatening disabilities that can greatly
affect the quality of their lives. For example, osteoporosis, due to a natural decline in bone density
after menopause, affects mainly women (50).

There has been considerably more research on gender and longevity in industrialized countries than
in developing countries. Senenayake points out that health policies seem to assume that men and
women's problems converge after menopause (49), whereas, in fact, they continue to be distinct. She
notes, for example, that there is a lack of sex-specific data for elderly people in developing countries.
However, the available data reported from developing countries indicate similar gender differences
worldwide: women have significantly higher rates of arthritis, osteoporosis, diabetes, and hyperten‐
sion than men (51). In a study of adult diseases in Bangladesh, Malaysia, Jamaica, and the United
States, Strauss et al. found that women reported more health problems than men, regardless of eco‐
nomic status (52).

Older women in both developing and industrialized countries are more likely to live alone than men
(53). As noted above, isolation can severely affect the health of older people, and given the lower
economic status of women, they are less likely to be able to seek help (50). A study of elderly males
and females in Egypt, for example, found that females who had lived all their lives in rural areas and
were living in a fair or poor residence were more likely to be disabled than women in better circum‐
stances (54). For Egyptian males, only illiteracy was associated with disablement. This was at‐
tributed to the fact that literacy is much more prevalent among men, and those who are illiterate are,
therefore, more likely to be poor. For women, living in rural areas is associated with having large
families and a tendency to rely on traditional healers for births and medical needs. They are, thus,
more exposed than men to poor medical care for reproductive healthcare and, consequently, more at
risk of infection. They also have less access to medicines to treat morbid conditions. For women but
not for men, living alone was associated with increased odds of disablement (54).

An interesting study by Rahman found important gender differences in elderly mortality in Bangla‐
desh (55). In a longitudinal study in the Matlab surveillance area, a large sample of men and women
aged 60 years and older were followed for eight years to determine the impact of several social, eco‐
nomic and demographic variables. The study found that household heads, whether male and female,
had lower mortality, and the presence of a partner had a significant positive impact on men, but a
positive impact on women only when their husbands were the heads of the household. Moreover, the
presence of an adult son was correlated with lower mortality among women but not men. These
findings indicate that individual access, to resources as opposed to joint access, is an important de‐
terminant in the survival of elderly people (56).

In industrialized countries, the impact of gender on the biological determinants of longevity is also
evident, for example, in the quality of life of elderly people. In a study of 14,000 men and women
aged 60 years and above living in their homes in Britain, the gender differences were found in living
arrangements for people living with severe disabilities (56). Half of these older women lived alone
compared to one-quarter of older men. Most men with severe or moderate disability lived with their
spouse and received care from them, whereas most women lived alone and had to rely on help from
outsiders.

The British study examined self-assessed health to test the validity of the common assumption that
women over-report morbidity (57). There was a little gender difference in self-assessed morbidity,
once class, income, age, and level of functional disability were taken into account. In fact, results of
multivariate analysis indicated that, when the greater functional disability of older women was in‐
cluded, older women reported less poor health than older men. These findings illustrate the impor‐
tance of re-examining common gender-based assumptions and of assuring that comparisons be‐
tween men and women are based on similar socioeconomic and demographic groups. Moreover,
gender relations and their impact on biological factors are changing, as women increasingly assume
positions traditionally occupied by men and vice versa.

Several studies of the ‘will to live’ have found that women have a weaker desire to prolong life than
men, in terms of refusing life-sustaining care (57–58) or a wish to die sooner if terminally ill (59–
60). In a study of gender differences among men and women aged 70 years or older in Israel, the
will to live was found to be affected by the state of health of the elderly, those in poor health more
likely to show the gender differences referred to above (59). As in other studies, living with a partner
was a significant predictor of the will to live among men, but not among women (61–62).

Gender differences in consequences of health and illness

This section reviews research on how gender affects the social, economic and biological conse‐
quences of health and illness, focusing on three non-communicable diseases or conditions: diabetes
for social consequences, domestic violence for economic consequences, and occupational health for
biological consequences.

Gender differences in social consequences of health and illness The gender differences in the social
consequences of health and illness include how illness affects men and women, including health-
seeking behaviour, the availability of support networks, and the stigma associated with illness and
disease. Men and women respond differently when ill, in terms of time before acknowledging that
they are ill, recovery time, and how women and men are treated by their families and society.

In developing countries, men seek treatment more frequently at formal health services, whereas
women are more likely to self-treat or use alternative therapies. This has been explained by factors,
such as multiple roles of women which limit their activities mainly to the domestic sphere and make
it difficult for them to go to clinics during opening hours. By contrast, traditional healers or commu‐
nity shops are easier to access and will often accept delayed payment or payment in kind or delayed.
Traditional healers also provide explanations in ways that are easily understood, in contrast to the
more scientific explanations of clinic staff (3). Women are often treated in an inferior way at health
services and are blamed for coming late or for not bringing their children for regular immunization
or check-ups. This only exacerbates women's reluctance to access healthcare, even when other ac‐
cess barriers are removed (63). Insensitive treatment by health personnel is also a problem in indus‐
trialized countries, although in these situations women have more options for restitution.

The lower social status of women influences how society responds when they are affected by stig‐
matizing illnesses, such as HIV/AIDS, leprosy, tuberculosis, and mental illness. While both men
and women suffer considerable discrimination and from society, women are more marginalized by
these health problems.

The example of diabetes, a non-communicable disease, demonstrates the gender differences in its
social consequences. Research on gender differences in the social consequences of diabetes is limit‐
ed, especially in developing countries. Even in industrialized countries, the studies in this area are
difficult to compare because they deal with different variables, measurement tools, and outcomes.
However, it is possible to draw some conclusions from the existing literature which are relevant
from a gender perspective.

A recent study from Trinidad found that men with type 2 diabetes mellitus were less compliant with
treatment than women and that they were less satisfied with the way they were treated in the dispen‐
sary and clinic they attended. Men tended to smoke and drink alcohol much more frequently and,
hence, were predisposed to a wider range of health risks, including hypertension and cerebrovascu‐
lar and cardiovascular diseases. The authors hypothesized that men with diabetes probably had a
lower life expectancy than women (64).

Some evidence from India showed that boys have better access to care for insulin-dependent dia‐
betes mellitus (IDDM) than girls. The reasons were not studied but it is likely that son preference
plays a role here, in keeping with other health-related research findings. Sridhar noted that mothers
tended to take responsibility for looking after diabetic children, which could result in alienating fa‐
thers and making them uninterested in helping to care for their children (65).
A common finding in developing countries is that urban dwellers have a higher prevalence of dia‐
betes than rural residents because of the shift from low to high fat intake (66–68) but there does not
seem to be a consistent pattern of gender differences within this rural-urban categorization.

Studies on gender differences in diabetes in industrialized countries have focused on how men and
women or girls and boys cope with the illness, including the types of coping strategies they develop.
Perhaps the most common finding is that women and girls generally have a more negative way of
dealing with diabetes than men and boys. Anxiety and depression are more common among females
(69–71). In a sample of adolescents in the United States, even after controlling for other correlates,
such as levels of knowledge about diabetes and metabolic control, girls were less positive about their
illness than boys (71).

More research is needed to understand the link between diabetes and depression (71). Some re‐
searchers have reported a higher incidence of eating disorders among diabetic adolescent girls than
among boys with IDDM or than among non-diabetic girls (72). Another possible explanation is that
girls may internalize stress more than boys who tend to deal with their stress by more positive be‐
haviour, such as practising sports and following a controlled diet. Cruickshanks reported that adoles‐
cent diabetic girls are engaged in fewer physical activities than boys, possibly contributing to poorer
diabetic control (73).

As has been found in other studies cited in this paper, the assistance and emotional support received
from their spouses has been found to influence health outcomes for people with diabetes. A study of
men and women with diabetes over a 10-year period found that male patients reported more satisfac‐
tion with the support received than women (74). Similarly, wives of diabetic patients reported fewer
problems in giving medication and in testing blood glucose levels than did husbands of female pa‐
tients. Men with diabetes received more support from their partners than women, as demonstrated
by the greater attendance of wives in education programmes than husbands of diabetic women. Men
reported better self-care, such as eating meals on time, less binge eating, and less late insulin injec‐
tions. Men also recounted fewer incidents of ketonuria, better blood sugar levels, and fewer diabetes-
related complications. Men generally mentioned greater satisfaction with their diet and their treat‐
ment regime. Whereas men were less likely to miss work or activities because of their disease,
wives of diabetics reported missing more work because of their husband's condition than husbands
of female diabetics (74). This again indicates the greater support received from women by men who
are ill than the reverse. Similar results concerning positive coping behaviour of men and support
from spouses have also been reported elsewhere (75–77).

Research in Sweden on coping strategies of men and women with type 2 diabetes found that women
used more negative coping strategies, including resignation, protest, and isolation, whereas men
took a more problem-solving approach (78). Another Swedish study found that men under-estimated
diabetes-related problems more than women and worried less about long-term complications. How‐
ever, they were more concerned about the impact of illness on their personal freedom. Although
women were more worried about their health, they were able to find positive aspects in having dia‐
betes. Younger people also had more positive attitudes than older people, although they were more
likely to consider that the disease had negatively affected their relationships with others (79).
Research in the United Kingdom found similar results as in the Swedish research. Reporting on in-
depth interviews with girls and boys with chronic diseases—type 1 diabetes and asthma—Williams
found that youngsters managed their conditions in “gendered ways, with the aim of projecting differ‐
ent, gendered identities” (80:394). The majority of girls adapted to the illness by incorporating it
into their social and personal identities. Boys tended not to identify with the illness but rather to find
ways of combating it or keeping it at bay. These findings support the observations of Charmaz (5)
and Prout (81) who emphasized the stigmatizing impact that chronic illness can have on males at
different ages. The greater acceptance by girls of their condition had detrimental consequences in
that they had lower expectations of themselves and were also less capable of managing their illness
by diet and exercise as well as boys did. Boys tended to use exercise as a means of keeping their
blood sugar under control, whereas girls were more likely to give themselves more insulin instead.

Gender differences in the economic consequences of illness

The gender differences in the economic consequences of illness include how work of men and
women is affected by illness, such as availability of substitute labour, opportunity costs of health-
related actions, available income, and the impact of economic policies.

When poor women in developing countries are ill, they tend to delay seeking modern treatment until
their symptoms are too severe to ignore, meanwhile perhaps visiting a traditional healer or local
pharmacy. Thus, they take longer to recover and often return to work before they have completely
recuperated (82). When men are ill, others encourage them to seek medical help, and hence they are
appropriately diagnosed and treated earlier than women. They also receive greater care from wives
and others and are not expected to perform other duties until they are better. Women often substitute
for their husbands in agricultural work when they are ill but husbands rarely substitute for their
wives, and only essential duties are assumed by other family members. When women recover, they
are faced with many pending tasks, in addition to their normal work. Those who own small busi‐
nesses lose necessary income for daily survival, and many have to use their scarce resources for
medicines and other health-related costs (82). The fact that women are often paid less for the same
jobs as men also means that they have fewer resources to fall back on when they become ill, and
their control over their own earnings is often limited (83).

The impact of economic restructuring policies on access to and use of health services by the poor is
an issue of growing concern. Given that women universally occupy a lower socioeconomic status,
poor women, especially those in female-headed households, are most adversely affected by econom‐
ic adjustment policies. Health-sector reforms have sought to strengthen private financing, to decen‐
tralize services, and to improve service-delivery through private sources. A central question is
whether, in the interests of cost cutting and efficiency, costs will be transferred from the remunerated
economy to the unremunerated economy, where women predominate.

In this section, we use the example of violence against women to demonstrate the impact of gender
on the economic consequences of illness. The section does not separate the discussion clearly into
developing and industrialized countries (although examples of both are cited) because domestic vio‐
lence is a universal phenomenon found in all cultures and at every level of society, and the effects
are similar, although they may vary in intensity and severity. Partner violence is mainly aggression
by men against women and children, although men are also victims of domestic violence. In the
United States, it is estimated that males constitute only 10–15% of victims (84).

Relatively little information is available on the cumulative economic impact of domestic violence
but there is growing evidence that it adversely affects women and children's mental health and op‐
portunities for a productive life. Among low-income groups, poverty may exacerbate marital dis‐
agreements, and it may be more difficult for poor women to leave violent situations because they
have less access to outside help or accommodation (1). It is well-known that violent partners fre‐
quently obstruct efforts of women to seek help for themselves and their children, and poor women
have little economic power in such situations. The impact of domestic violence is magnified in areas
with fewer material resources (85). There may also be substantial under-reporting among the higher
socioeconomic groups.

Victims of domestic violence have more difficulty keeping a job because they often miss work due
to physical injury. Many female victims of physical or sexual violence are unable to work because of
their injuries, or are stalked or harassed at work. The fear and discomfort entailed affects their abili‐
ty to perform, and they may also be forced to leave their job when the situation becomes unbearable.
Women who resist a harassing male colleague or superior may be dismissed (86).

Children who witness domestic violence exhibit many of the same emotional and behavioural prob‐
lems as children who have been sexually or physically abused, including poor school performance
and somatic health complaints. Those who have been abused are more likely to be abusive as adults.
The cycle of poverty, gender violence, poor health, and limited economic opportunities is perpetrat‐
ed throughout the generations (87).

In developing countries, women who are totally dependent for economic livelihood upon their hus‐
bands are particularly affected when they suffer domestic abuse. In a study in Mexico, women at risk
of abuse and who lived with their own parents or in an extended family were much more likely to be
protected from it than those who lived in a nuclear family situation (88). Those who were unable, for
economic reasons, to leave their husbands were the worst-off and least able to escape the situation.
Finkler explains that poor Mexican men also suffered a different kind of abuse: being looked down
upon in society, their dignity is challenged, and they may try to compensate for their frustration
through mistreating those who cannot retaliate.

In India, dowry-related violence, sometimes leading to deaths by murder or suicide, is increasingly

being documented. Dowry, a Hindu tradition, was originally a way for parents to share their inheri‐
tance with their daughters who were not allowed to inherit property. As Fischbach and Herbert ob‐
serve, this practice has become a ‘crucial marital transaction’ and a way to ‘get rich quick’ (85).
Bridal abuse is a way of putting pressure on her family to give them more of their assets, and when a
wife is unable to provide them, she may resort to suicide or be killed. Women rarely seek medical
help, mainly because of shame. A study in Bangladesh found, for example, that 66% of women were
silent about their experience, mainly because of culturally-endorsed acceptance of violence or fear
of stigma and greater harm (89). In Uganda as well, lack of economic autonomy was an important
reason that women stayed in abusive relationships, “…many of the women experienced poverty so
severe that they had literally no option but to remain with husbands who routinely battered them.
Their worth and social acceptance was found in marriage and children, making separation or divorce
almost impossible” (90).

Another pervasive form of violence against women is rape. This is considered to be among the most
under-reported health problems in the world (85), a crime that can have serious psychological, so‐
cial and economic consequences. In several parts of the world, women who have been raped may be
seen as having brought dishonour on their families. In some countries, rape victims may be beaten,
killed, or driven to suicide (85). In these situations, even those who survive are likely to face precar‐
ious economic futures, as they may be driven away from their families and be left without social or
economic support (85).

Gender differences in biological consequences of illness

Generally, men are more vulnerable to major life-threatening chronic diseases, including coronary
heart disease, cancer, cerebrovascular disease, emphysema, cirrhosis of the liver, kidney disease, and
atherosclerosis. Women suffer more from chronic disorders, such as anaemia, thyroid and gall blad‐
der conditions, migraine headaches, arthritis, colitis, and eczema. The biological advantage of
women appears to be related to their ability to bear children and the physiological systems that per‐
mit pregnancy and child bearing, whereas men's health advantage seems to be due to lower levels of
role stress, role conflict, and lower societal demands (91).

Men and women have different responses to drugs for treatment. These gender differences are not
only biological: gender plays an important role in determining healthy or unhealthy life styles. As
men and women modify their behaviour to reduce or increase certain risks, such as stress relating to
high-pressure jobs, their respective vulnerability can change over time and across societies.

The gender differences in the biological consequences of health and illness can be illustrated by the
example of occupational health. Until recently, little attention was paid to gender differences in oc‐
cupational health, and most social science literature focused on differences in exposure to health
risks (92). The literature on tropical diseases found significant gender differences in the impact of
infectious diseases on men and women because of their differential exposure to vectors, such as
mosquitoes or sandflies (82). Social scientists are now investigating the impact of different kinds of
work environment on health of men and women but considerably more research is needed to con‐
firm early findings in this regard. Research in industrialized countries has shown that working out‐
side the home is related to improved health for women (93–95) because of increased self-confidence
and economic independence. Similarly, among men, employment is associated with increased life
expectancy (96–97), and unemployed men are at greater risk of psychological problems and early
mortality (97).

In developing countries, however, there is insufficient evidence to conclude that non-domestic

labour has a positive impact on women's health. Women may suffer more ill-health because labour
conditions are generally much poorer in developing countries, their status is lower than men's, and
they often assume the large burden of domestic work, in addition to paid labour (83). Research on
factory work in both low- and high-income countries has found that women who are employed in
monotonous and repetitive work are likely to develop repetitive strain injuries (83) or to be exposed
to carcinogenic substances (98, 99). Men are more often employed in dynamic jobs involving physi‐
cally strenuous activities, such as construction, with considerable lifting and moving of heavy loads.

Work-related accidents resulting in death seem to be much more common among men in both indus‐
trialized and developing countries because men are employed in occupations involving greater dan‐
ger, such as transportation, construction, mining, and fire-fighting. Men in developing countries are
also more at risk of accidents than men in high-income countries because of poorer safety regula‐
tions and protective equipment (83).

Because of women's double responsibility for both household and outside work, and their lack of
decision-making power and often arduous tasks in the workplace, female managers tend to experi‐
ence more ‘negative stress’ than men (100). In several studies, Oslin has shown that women at all
levels of employment reported more such stress (83). For example, women who had to work more
than 10 hours of overtime per week had a higher risk of heart attacks than other women, whereas
men who worked the same amount of overtime were at lower risk. Moreover, women's level of nega‐
tive stress increased at the end of the working day, whereas men's level of negative stress decreased
considerably.

DISCUSSION

This paper has reviewed many studies and health and illness examples as they relate to gender dif‐
ferences using a framework from the field of tropical diseases. Clearly, the framework which links
gender to the social, economic and biological determinants and consequences of tropical diseases is
applicable to non-infectious diseases and conditions too.

Several conclusions regarding the importance of gender for understanding health and illness can be
derived from the studies reviewed in this paper. First, gender clearly plays a role in the determinants
and consequences of poor health, and it can no longer be assumed that a male model for health also
applies to women. The way in which gender affects these determinants and consequences may vary
according to the conditions selected and according to the characteristics of the population studied.
However, gender analysis is key to understanding the experience of health and how to intervene to
prevent illness.

Perhaps, the most common finding across the different chronic diseases and conditions reviewed is
the importance of social support, especially by spouses and other family members, in helping people
cope positively with their condition. There was a widespread gender bias towards men in terms of
the support received from their families, and this helped them respond better to their illness. Women
were less likely to receive support, leading to less positive coping. Women were also more prone to
accept their condition as part of themselves, rather than to see it as a challenge to be overcome, as
their male counterparts tended to do.
The involvement of both men and women in health education and interventions was shown to be an
important determinant of their successful uptake. This demonstrates that gender stereotypes need to
be examined critically as they stand in the way of the improvements in health that are known to be
effective. For example, it was seen that selecting women for nutritional education because they are
responsible for the preparation of meals means that men are generally excluded, yet it is men who
are heavily involved in the production, sale, and purchase of food. Similarly, not understanding the
dynamics of age, ethnicity and gender can be detrimental to desirable health interventions. This was
seen in several examples discussed in the paper.

The framework discussed in this paper separated out social economic and biological determinants
and consequences of health and illness to bring an organizing structure to a vast number of individ‐
ual studies on a range of varying health conditions. However, it must be recognized that these deter‐
minants and consequences also interact with one another as seen, for example, in the case of domes‐
tic violence. Women who are victims of violence miss more work than other women because of
their injuries and hide their injuries from others, including health services, because of social stigma
and fear. Thus, the social, economic and physical aspects of the experience are closely inter-related.

In both developing and developed countries, awareness of the importance of a gender analysis in
health is growing, with respect to both infectious and chronic diseases. Despite a rapidly-expanding
literature in this area, comprehensive, integrative analyses are few. It is difficult to compare the
many studies in this field as they are based on populations with different ethnic, socioeconomic and
demographic characteristics, different geographic and ethnic groups, and on different diseases and
health conditions, or different symptoms of these diseases and conditions. Moreover, these interrela‐
tionships may change over time, with, for example, changes in marital status, age, or changes in so‐
cial and economic conditions. As a result, in-depth gender analyses of health and illness are very
few. If gender studies are to provide a useful basis for the development of policy, planning, and
health services, a more systematic approach to studies in this area are needed. Frameworks such as
the one used in this paper are a useful beginning.

Women's health programmes, and increasingly gender studies programmes, are being incorporated
into university health curricula. Nonetheless, such programmes are still mainly pursued by social
scientists and are not seen as a mandatory part of biomedical training. Mainstreaming gender studies
into biomedical programmes can greatly enhance awareness of a wider range health issues, thereby
contributing to the prevention of illness and the mitigation of negative health outcomes. It can also
stimulate much needed research on gender differences between developing countries and developed
countries and on the impact of gender on the epidemiological transition from infectious to non-com‐
municable diseases.

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